CQC has recently published statistics for the ratings of GP practices throughout England, which included the fact that there has been a 136% increase in the use of the ‘Give us Feedback about Care’ function on the CQC website for PMS; such feedback and complaints being one of the key triggers for CQC inspections at present.

This is therefore a useful moment to assess how CQC arrived at its current inspection framework, the consequences of critical inspection reports and how the sector can learn from the inspections carried out under the framework to date.

As GP practices will be aware, the CQC announced plans to introduce a special measures framework for the sector back in August 2014. Through this framework, CQC committed to working with NHS England to provide coordinated responses to concerns that GP practices were providing inadequate care.

Outcomes of the Pilot for the new Framework

Through the initial pilot, CQC rated for its five key questions (safe, effective, caring, responsive and well-led) and for six population groups (older people; people with long-term conditions; families, children and young people; working age people, including students and those recently retired; people whose circumstances may make them vulnerable; and people experiencing poor mental health, including dementia).

At the conclusion of the pilot, CQC announced that it would be implementing an approach of placing inadequate practices in special measures; providing a specified period of time for re-inspection no later than six months after the initial rating was confirmed. If following re-inspection, the GP practice in question has not sufficiently improved, CQC will begin proceedings to cancel the provider’s registration.

In addition, CQC advised that if GP practices are rated as requires improvement on more than one consecutive inspection, CQC would consider this to indicate that the provider is not demonstrating the necessary leadership or governance processes and will decide whether this represents a breach of Regulation 17 (good governance).

A third consecutive finding of requires improvement would result in a formal management review meeting to consider next steps and the potential use of enforcement powers. This relates to both individual GP practices and larger primary care providers. Enforcement action could apply to either an individual practice or the wider provider group where concerns are considered to be systemic across the practice group.

CQC advised that the act of placing a GP surgery in special measures is an opportunity for CQC to help the GP practice improve. A ‘package of support’ should be provided by NHS England. At the time of the announcement, CQC’s Chief Inspector of General Practice said:

“We will only cancel the registration of a GP practice if we think it is absolutely necessary – and in any case, our priority will be to help the practice improve if that is appropriate. In these situations, we will work closely with NHS England who will ensure that people registered at that practice continue to have access to safe and high-quality general practice”.

During the pilot, CQC continued to publish summaries of the number of GP practices rated and their overall ratings, linking to the specific inspection reports in its media alerts. Whilst the publication of inspection reports on the CQC website is standard practice, publishing sector-specific updates in which the GP practices are listed is an unusual step for CQC to take and demonstrated CQC’s new focus on this sector.

Unintended consequences of special measures for GP practices

Whilst drawing attention to published reports is predictably damaging to the reputations of the named GP practices, the British Journal of General Practice analysed the impact of the new inspection framework pilot on the sector and found a number of unintended consequences of GP practices being placed in special measures; including:

• Difficulty with recruitment and consequent staffing costs

Whilst recruitment and staffing costs are a constant concern within the sector, it appeared that the announcement of a practice being placed in special measures exacerbated existing issues. Potential staff members withdrew applications, citing concerns with challenging environments. Where potential staff members agreed to apply, there was a tendency to request a financial premium to mitigate their concerns; however, GP practices spoke of concerns that higher salary rates may be a barrier to merging with other practices in due course.

• Undue strain on management systems

The scrutiny arising from being placed in special measures itself placed significant additional strain on the time, workload and resources of practices. This was found to risk the ongoing safe running of the practice, as staff time was consumed with writing action plans and responding to CQC/ NHS England concerns under tight deadlines, in circumstances where governance structures had already been found by CQC to be weaker.

• Staff morale

Staff reported that working in a challenging environment was a burden over and above their normal tasks, but the publication of an inadequate rating was ‘a huge toll on staff, many of whom work in their own local communities. Reports included staff members being harangued in public spaces. However, in 30% of practices engaged with the study, staff also reported that the process of special measures was significantly less stressful where they felt that the communication with CQC and NHS England had been good and transparent about the improvements needed.

• Patient morale

Patients suffered an inevitable loss of confidence in their GP practice when it had been rated inadequate. It was feared that this could correspond with increased disengagement with practices and risk to health outcomes.

• Increased financial costs

The previously discussed potential of higher salary rates to attract and retain staff to an inadequate practice are combined with strains on existing personnel seeking to meet the demands of the special measures process. The study found that this was a further strain on practices with limited budgets, given that there is a correlation between practices in special measures and those practices with lower income per patient.

These are sobering reminders that a critical inspection report has wide-ranging and long-lasting impacts on a GP practice’s ability to function within the sector. It is therefore vital that GP providers take the opportunity to learn from the sector’s experience and consider how they can maintain and improve their practices to avoid inadequate ratings.

Trends of Inadequate GP Practices

Analysis of common concerns highlighted in the findings of inadequate practices indicate the following trends:

Safe

• No analysis of significant events
• Safeguarding protocols are not robust and staff are not appropriately trained
• Not screening staff properly when recruiting

Effective

• No clinical audits or evaluation of the service
• Not caring for patients using up-to-date best practice

Caring

• Little concern for patient’s privacy and dignity in reception and waiting areas
• No lists of people at the end of life or sharing this information with out-of-hours services

Responsive

• Poor availability of appointments at times which suit patients
• Difficult to contact the practice by telephone
• No same-sex clinicians

Well-led

• Absence of vision for the organisation
• Lack of clarity in roles and responsibilities to run the practice day-to-day
• Poor visibility of leaders and no whole-practice meetings

CQC has published anonymised examples for each of the above findings, which are useful guides for GP practices as insight into CQC’s considerations.

Given CQC’s aforementioned emphasis on Good Governance, the following example is demonstrative of the type of concerns that CQC intends to highlight to GP practices:

What does an inadequate practice look like? Examples from our GP inspections

Key question: well-led?

Population group: All groups

This example relates to Key Line of Enquiry (KLOE) W2: Do the governance arrangements ensure that responsibilities are clear and that quality, performance and risks are identified, understood and managed?

When we inspected

The practice did not hold any governance meetings. The GP informed us that he discussed governance with a local peer group but this was on an informal basis and no minutes were kept.

There was no risk log to address potential issues, such as control of substances hazardous to health (COSHH) or a robust analysis of significant events over time.

Why this is inadequate?

There is no effective clinical governance in the practice and no effective system for identifying, capturing and managing issues and risks.

We would strongly recommend that all providers within the sector stay abreast of CQC guidance for the sector to understand how they can remain compliant with the expectations that CQC has across all rated domains. Practices can use the examples of others’ non-compliance to raise their practices and ensure that they are not placing themselves at risk of critical inspection reports and the consequences of being placed in special measures.

We represent and advise GP practices through challenges to CQC reports and responses to enforcement action taken by CQC, as well as with employment and commercial issues relevant to GP practices. We understand that every business is different and we work with you to understand your circumstances and explore your options, to agree the most appropriate strategy to achieve your aims. We can provide you with advice and representation throughout the CQC process, alongside support with ancillary issues such as safeguarding matters, inquests, employment advice and assistance dealing with banks, commissioners, families and the media.

If you have received a critical inspection report or alternative enforcement action from CQC, please contact our health and social care lawyers to discuss how we can help at Nicole.Ridgwell@LA-Law.com.